Thoracoabdominal aortic aneurysm technique for Perfusionist and cardiac surgery

1. Sittisard saikaew
Chiangrai Prachanukroh Hospital
Perfusionist Division, Cardiovascular and Thoracic surgery
Perfusion Techniques for Surgery
of ThoracoAbdominal Aortic Aneurysm

2. Pathogenesis
Aortic Aneurysm Marfan syndrome cause of aortic aneurysms (36%) : fibrillin-1, Ehlers-Danlos,
Loeys Dietz Syndrome autosomal dominant disorder.
Genetic mutations
02
Takayasu arteritis, giant cell arteritis and rheumatoid aortitis can cause
destruction of the aortic media and progressive aneurysm.
Both chronic, nonspecific aortitis
03
Infection can produce a saccular “mycotic” aneurysm.
Staphylococcus aureus, Staphylococcus epidermidis,
Salmonella and Streptococcus
Infection
04
Smoking, Hypertension, Obesity, hyperlipidemia, Chronic
obstructive pulmonary disease COPD and Family history
Atherosclerotic
05
primarily the result of age-related medial degeneration which is characterized by
changes in elastin and collagen. that reduce aortic integrity and tensile strength
Degenerative disease
01

3. The Crawford classification of
thoracoabdominal aortic aneurysm repairs.
Prognosis following TAAA open
repair varies according to the
type of aneurysm undergoing
repair, with extent I, II and III
carrying a higher intraoperative
and postoperative complication
rate, especially regarding to
spinal cord ischemia,
pulmonary complication and
renal failure

4. Traumatic aneurysm
Saccular aneurysms
Pseudoaneurysm
Penetrating Atherosclerotic Ulcer (PAU)
Connective tissue diseases
Chronic dissection
Aortoiliac occlusive disease
Atheromatous plaque
Endovascular
stent graft
Open repair

5. Indications for Repair
Urgent aneurysm repair
Rupture
01
Resulting in malperfusion or other life altering complications
Degenerative DTAAs and TAAAs with super imposed acute dissection.
Acute dissection
02
Pain consistent with rupture and unexplained by other causes
Compression of adjacent organs
Symptomatic states
03
Patients with connective tissue disorders threshold is lowered
Documented enlargement >1 cm/year or substantial growth
approaching absolute size criteria
Absolute size > 6.5 cm
04

6. Preoperative evaluation
Has become the gold standard for preoperative imaging
Vascular disease, peripheral vascular, Cerebrovascular disease
CT with 3D Reconstruction
01
Transthoracic echocardiography is noninvasive and can satisfactorily
evaluate both valvular and biventricular function
cardiac catheterization : significant history of angina EF < 30%
Cardiovascular risk stratification
02
Chronic and Acute renal disease with dialysis
Renal function : BUN Cr GFR, aids in estimating
perioperative risk and adjusting treatment strategies
Renal Function
03
Single lung ventilation
Arterial blood gas Spirometer, FEV1 greater than 1.0 and a
PCO2 less than 45 mmHg ,Smoking cessation
Pulmonary function
04

7. aneurysmal diameters greater than 6 cm,
with a 14% combined risk of rupture,
dissection, and death
the 5-year risk of rupture doubled from
16% for aneurysms 4 to 5.9 cm in
diameter
31% in aneurysms 6 cm or more
in diameter.
CT PREOPERTIVE
EVALUATINO

8. Anesthesia Monitoring
Swan-Ganz catheter and trans esophageal
echocardiography probe when necessary and are
aggressively maintained
TEE, PA catheter
Continuous monitoring. Cardiac evaluation and are
routine in our institution
EKG, Temperature, Pulse oximeter, Foley,
External defibrillator
Suction a lot of blood in operation filed.
Keep body temp >32 OC
Cell saver, Rapid infusion device,
blood warmer, Bair hugger, Blanket
Single lung ventilation.
may not be critical in extent IV TAAA repairs.
Deflating the left lung reduces retraction trauma to
the lung, improves exposure, and alleviates the risk
of cardiac compression
GA, Double lumen endotracheal
The arterial catheter is placed in the right and lower
extremity arterial line.
Interrupted during aortic clamping.
A large-bore CVP line for volume return.
Arterial lines, CVP
.
Lumbar CSF drain, NIRS
Enhance spinal perfusion by decreasing the
pressure on the cord during aortic cross-clamping.
Near-infrared spectroscopy (Circulatory arrest)

9. Incision and exposure: the patient is positioned such that the upper body is at 60 degrees from horizontal and
the hips are at 30 degrees from horizontal. A sigmoid-shaped skin incision is made from behind the left scapula,
along the 7th rib, across the costal margin, and toward the left periumbilical region. The chest is entered through
the 6th intercostal space. Left medial visceral rotation and circumferential division of the diaphragm enable
exposure of the entire thoracoabdominal aorta. The use of table-mounted self-retaining retractors maintains
stable exposure throughout the procedure
Surgical
Approach

10. ORGAN PROTECTION
Abdominal visceral organs
Protection
Lung Protection
Spinal cord Protection
Renal Protection
Brain Protection
Heart Protection
Hemodynamic Support during Aortic Cross-Clamping
Proximal aortic cross clamp application induces a significant increase in Cardiac Afterload
Sudden
Afterload reduction following clamp release is associated with an acute relative hypovolemic
and systemic hypotension
Extracorporeal circulation support provides after load reduction and continuous end organ
perfusion during Aortic cross clamp period

11. Spinal cord PROTECTION
Paraplegia has been a major concern of TAAAS in 1951 Cooley
Interrupt lower body blood flow distal organ ischemic (spinal cord)
Replace Aorta with graft result in permanent loss of spinal cord
blood supply
Being nervous tissue, the spinal cord tolerates ischemia poorly,
paraplegia results 30% were reported, but with advances in surgical
management , rates below 10 % in the 1980
Blood supply of spinal cord three longitudinal arteries : anterior large
than two posterior (anterior spinal artery blood flow 75%)
02
03
04
01
These radicular arteries enter : Cervical, Thoracic and Lumbar.
Cervical arise from vertebral, cerebellar ,ascending cervical, all from
aortic arch vessels rarely compromised during DTAA
Arteria radicularis mgna (Adamkiewicz) 70% from intercostal and or
lumbar arteries on the left side T8-L1
05
06
Mkalaluh et al : The Journal of Thoracic and Cardiovascular Surgery, December 2018

12. Spinal cord PROTECTION

13. ORGAN PROTECTION
Upper body MAP is maintained at 70-90 mmHg and lower body
60-70mmHg, brain and spinal cord protection (subclavian, hypo
gastric, median sacral arteries blood supply when Aortic clamp)
Use cerebrospinal fluid drainage, maintained at < 10-15 mmHg,
fluid drainage <15-25 ml/hr
Distal perfusion with Left heart bypass or Fem-Fem bypass
Mild passive hypothermia (32-33°C nasopharyngeal)
Avoid hypothermia-induced arrhythmia, reduce metabolism
02
03
04
01
To minimize ischemic damage to the kidneys,
administer cold crystalloid renal solution
To protect the abdominal organs, perfuse the Celiac axis and
SMA with isothermic blood from the circuit
05
06
Mkalaluh et al : The Journal of Thoracic and Cardiovascular Surgery, December 2018

14. RENAL PERFUSION
Passive Shunts for Renal perfusion and mechanical support, Observational studies
performed in the 1980s and 1990s found that renal perfusion with isothermic blood
during LHB was associated with an increased incidence of acute renal failure
Jacobs and colleagues posited that this association was the result of insufficient renal
perfusion pressure and proposed using catheters equipped with maintain perfusion
pressure at 60 mmHg or greater (flow 200-280 mmHg monitor Urine output)
In patients with chronic hypertension and/or preoperative renal insufficiency, they
recommended maintaining higher pressures (i.e. 85 mmHg)
From retrospective study 359 patients who underwent TAAA with LHB, compare warm
and cold blood techniques produce similar results in ARF (clod 22%,warm 23%).
Selectively perfuse the renal arteries with continuous cold blood (4–8
o
C) mortality lower
27% than continuous warm blood mortality 56% p<0.02
History
The Journal of ExtraCorporealTechnology; JECT. 2012;44:P31–P37
Open TAAA repair involves Clamping of the descending thoracic aorta for 30 minutes.
Current series of TAAAA repairs indicate a acute renal failure 20-30% post operation and
leading to dialysis in 3-6% caused by ischemia, several selective perfusion strategies

15. RENAL PERFUSION
We routinely use intermittent clod crystalloid perfusion.
Recent studies continue to support using clod crystalloid perfusion to provide renal protection. Significant out
come improvement, 172 patients intermittent renal perfusion either Cold blood or clod lactated ringer’s
solution not different of incident ARF requiring dialysis was 3%, cold blood higher incidence of paraplegia 6%
Delivered through Centrifugal pump or Roller pump (cardioplegia circuit) with
bifurcation connector to Balloon perfusion catheters 9-16 Fr.
Concomitant systemic warming through femoral perfusion to prevent systemic
hypothermia
History
M. Ouzounian et al: Operative Techniques in Thoracic and Cardiovasculary Surgery 23:2-20,2018
Give the established efficacy of hypothermia of protecting organs from ischemic injury.
localized selective renal hypothermia Target renal temperature is 15
o
C or less
throughout the ischemic period

16. RENAL PERFUSION
Cold crystalloid renal perfusion solution
Lactated Ringer's solution (1000 ml)
Mannitol (12.5 g/L)
Methylprednisolone (125 mg/L)
Technique for Cold crystalloid renal perfusion
Administer 4 °C
Delivered through a roller pump, gravity infusion
Balloon perfusion catheters
Initial bolus of 200–300 mL/kidney(total 400-600 ml)
Boluses every 10–30 minutes
Flow rates of 150–200 mL/min/branch
Total 1000 - 2000 ml (volume overload)
Cold crystalloid renal perfusion
provides excellent renal protection,(*1233patient) Crawford’s technique Particularly in high risk patients such as
those with renal artery occlusive, preoperative renal dysfunction or ruptured aneurysm. Lower rates of post op renal
insufficiency, multiple organ failure
M. Ouzounian et al: Operative Techniques in Thoracic and Cardiovasculary Surgery 23:2-20,2018

17. VISCERAL
PERFUSION
Selective visceral
Continue perfusion
with isothermic blood
is given at a rate of
400 - 500 mL/min
The catheters
are connected to the
circuit via a Y-branch
Technique
The Journal of ExtraCorporealTechnology; JECT. 2012;44:P31–P37
Figure 10 Visceral and renal perfusion. Selective visceral perfusion with isothermic blood is given at a rate of 500
mL/min through 9-Fr Pruitt balloon catheters inserted into the celiac axis and the superior mesenteric artery (SMA).
The catheters are connected to the left heart bypass circuit via a Y-branch. To provide cold (4°C) renal perfusion, a
separate pump, set of lines, and 2 balloon catheters are connected to a cooling device; 9-Fr Pruitt catheters are
placed in the renal arteries, and cold renal perfusion is delivered approximately every 6 minutes at a rate of 300
mL/min for 1-2 minutes. Nasopharyngeal temperature is carefully monitored to avoid hypothermia-induced
arrhythmia. Our cooling perfusate consists of mannitol (12.5 g/L) and methylprednisolone (125 mg/L) with lactated
Ringer solution

18. BALLOON-TIPPED
PERFUSION CATHETERS
Irrigation perfusion catheters
balloon tipped cannula
Multiperfusion
Irrigation perfusion catheters
Irrigation perfusion catheters
Balloon tip cannula
maltiperfusion
Irrigation perfusion catheters

19. Clamp and sew techniques
Minimum of 30 min risk factor for Paraplegia and ARF 30%, Cerebrospinal
fluid (CSF) drainage and naloxone administration , extent IV, V
Passive Shunts for Renal Perfusion
Gott Shunt (Proximal to distal Aorta), medical manipulate
Left Heart Bypass
Reducing the afterload of the heart, Preservation of distal organ perfusion,
Low dose heparin 1 mg/kg (ACT > 280 sec),
Small hemodilution, Mild Hypothermia
Femoral Femoral Cardiopulmonary Bypass
Reducing the afterload of the heart, Preservation of distal organ perfusion,
High dose heparin 3 mg/kg (ACT > 480 sec) , Large hemodilution, Control
temperature
01
02
03
04
Perfusion Techniques

20. LEFT HEART BYPASS
The left heart bypass (LHB) circuit uses a centrifugal pump to deliver
oxygenated blood drained from the left atrium into either the femoral
artery or the distal aorta
LHB circuits deliver isothermic blood to organs (1500-2500 RPM)
radial MBP 80-90 mmHg
01
Selective renal perfusion is delivered through balloon
perfusion catheters
02
Concerns about high shear rates that could cause
hemolysis and coagulopathy when using high flow
rates through small-diameter catheters (1000-1500 RPM)
03
Nasopharyngeal temperature is carefully
monitored to avoid hypothermia induced
arrhythmia
04

21. Centrifugal pump Delphin Terumo Centrifugal head Circuit priming Cannulate
PREPARATION
for LHB Circuit

22. LHB Cannula
Malleable single stage venous
cannula Angled-tip
EOPA arterial cannula
Femoral arterial cannula
Malleable single stage venous
cannula Angled-tip
EOPA arterial cannula Femoral
Femoral arterial cannula

23. LEFT
HEART
BYPASS
The left atrium
The left inferior pulmonary vein
The distal descending thoracic aorta
The proximal abdominal aorta
Figure 7 Arterial return line of the left heart bypass circuit. To establish an inflow or arterial
return line, a 4-0 pledgeted polypropylene suture is used to secure a 22-Fr angled-tip
cannula placed in either the distal descending thoracic aorta or the proximal abdominal
aorta (ie, proximal to the left renal artery origin). Selection of the aortic cannulation site is
aided by careful examination of the preoperative imaging results to identify and avoid areas
with extensive intraluminal thrombus.
Figure 6 Venous drainage line of the left heart bypass circuit. Before cannulation, heparin is
administered intravenously at a dose of 1.0 mg/kg; the patient's activated clotting time is
confirmed to be 280 seconds. The pericardium is reflected or opened near the pulmonary
veins, away from the phrenic nerve. A 3-0 pledgeted polypropylene suture is placed at the
junction of the left atrium and the left inferior pulmonary vein in a mattress fashion. For outflow,
the left atrium is cannulated with a 24-Fr angled-tip cannula connected to the venous drainage
of the left heart bypass circuit and secured with a Rummel tourniquet.

24. CONDUCTION
for LHB Circuit
Pump Flow Inlet and Outlet Position Calculate flow

25. LHB Proximal anastomosis
LHB conduction:
Left heart bypass, placement of aortic clamps, and
opening the proximal descending thoracic aorta
After the aorta is clamped, LHB flow is increased toward a
target between 1.5 and 2.5 L/min to keep the patient’s
MAP around 80 mmHg. Distal aortic pressure 60-70
mmHg. ICP <15 mmHg drain <15 ml/hr.
The return line of the LHB circuit has a Y-connector
attached that splits pump return between the line going to
the distal aortic cannula and another line leading to two 9-
Fr Pruitt balloon-tipped perfusion catheters for later
delivery of selective visceral and renal perfusion

26. LHB Proximal anastomosis
Cell saver and rapid reinfusion :
Illustration of a modified cell saver system to enable rapid
reinfusion of shed blood. (Used with permission of Baylor
College of Medicine.)
However, a Y-connector is inserted into the cell saver line
just distal to the collection reservoir, which provides
microaggregate filtration (20 μm) to remove blood
component materials, clots and other debris.

27. LHB Proximal anastomosis
proximal anastomosis:
Tailoring the graft and constructing the proximal
anastomosis
after back-bleeding intercostal arteries are ligated
This ensures that the origin of each branch graft is
positioned slightly inferior to the origin of its paired artery,
and thereby facilitates the formation of gentle curves in the
branch grafts that help prevent the grafts from becoming
kinked. The anastomosis between the aortic graft and the
proximal aortic cuff is sewn

28. VISCERAL AND RENAL PERFUSION
Visceral and renal perfusion during the
intercostal patch anastomosis:
after the proximal anastomosis is completed, left heart
bypass is stopped, the distal aortic clamp and cannula are
removed, and the aorta is opened longitudinally down to
the aortic bifurcation.
left heart bypass during the proximal portion of the repair
followed by selective visceral perfusion with isothermic
blood and cold crystalloid renal perfusion while intercostal
and visceral arteries are reattached. (Used with
permission of Baylor College of Medicine.)

29. LHB Distal anastomosis
sequential Aortic Clamping and Distal
anastomosis :
after the patch reimplantation of the intercostal
arteries, the aortic cross-clamp is moved down to
the aortic graft distal to the intercostal patch,
thereby allowing reperfusion of the reimplanted
intercostal arteries. The distal end of the aortic
graft is trimmed to the appropriate length, and the
distal anastomosis is performed
Monitoring urine output
Flow rate in visceral and renal perfusion
Temperature renal perfusion ,body temp

30. LHB fourbranch anastomosis
Implant renal and visceral:
Left renal artery mobilization and anastomosis
After the graft has been de-aired and the
anastomosis completed, the clamp is removed.
Protamine sulfate is administered to reverse the
heparin. Indigo carmine is also administered
intravenously to assess the adequacy of renal
perfusion; ideally, blue dye should be visible in the
urine within 20 minutes.

31. FEMORAL-FEMORAL BYPASS
Partial and total CPB circuits drain deoxygenated blood (femoral vein)
while returning extra corporeally oxygenated blood to the body (left
femoral artery)
Distal aortic perfusion was provided at a rate of 1.5 to 2.5 L/min
(Keep upper body 80-90 mmHg, lower body 60-70 mmHg)
ICP <15 mmHg during CPB
01
Selective renal perfusion is delivered through balloon
perfusion catheters, flow rates of 150–200 mL/min/branch
02
Selective visceral perfusion is delivered through
balloon perfusion catheters, flow rates of 400–500
mL/min,
03
The heat exchanger of the CPB circuit allows
for variable cooling of the blood being returned
04

32. Femoral cannulation
Femoral arterial cannula
Femoral venous cannula
FEMORAL-FEMORAL BYPASS

33. Blood pressure control
Arterial pump
AV shunt
Renal and Visceral Perfusion
With CPS system circuit
Selective cold crystalloid renal perfusion
Isothemic blood to visceral perfusion
FEMORAL FEMORAL
BYPASS

34. Arterial Venous shunt
Connector with luer
venous line shunt
Clamp Arterial give between shunt and patient
oxygenated blood to Venous line (clamp venous line between shunt and
Increase preload oxygenator)
FEMORAL
FEMORAL
BYPASS

35. HCA Femoral Femoral Bypass
If aortic cross-clamping of the aortic arch distal to the origin
of the left carotid artery was not possible, Hypothermic
circulatory arrest was used (Kouchoukos)
Arrest heart ; Custodiol cardioplegia
Near-infrared spectroscopy (NIRS) monitoring
Fibrillating heart ; LV vent insertion
CA with Antegrade cerebral perfusion
01
Mkalaluh et al : The Journal of Thoracic and Cardiovascular Surgery, December 2018
02
03
04

36. HCA FEMORAL FEMORAL BYPASS
hypothermic circulatory arrest :
Repair of a descending thoracic aortic aneurysm
involving the distal aortic arch by using profound
hypothermic circulatory arrest (HCA).
Cardiopulmonary bypass is initiated (A) and a long
femoral venous cannula is advanced into the right
atrium. Drainage is augmented by cannulating the
left atrium through the left inferior pulmonary vein
or LV Vent. After the patient has been cooled
sufficiently to moderate hypothermia 25-28
o
C,
circulatory arrest is initiated. The aneurysm is
opened
(B) and the proximal anastomosis is constructed.

37. HCA FEMORAL FEMORAL BYPASS
hypothermic circulatory arrest :
Cardiopulmonary bypass is conduction
A Y-limb from the arterial line is connected (C)
to a side branch of the graft, after the proximal
anastomosis is completed.
The completion repair (D) is shown.
(Used with permission of Baylor College of Medicine.)

38. Perfusionist

39. Thank you